Welcome to the final issue for 2018. We present the findings of the Coroner’s Inquest into a resident death at an aged care facility in Oakden, South Australia, that occurred in 2008. The finding was delivered in September this year, more than 10 years after the death of the resident.
This Clinical Communiqué case study discusses the death of a patient who was at a significantly increased risk of medication harm. Recently discharged from hospital, the patient had been prescribed a new medication and treated with a medication requiring therapeutic monitoring (warfarin), all with the involvement of a number of different healthcare providers. The coroner’s finding highlighted the importance of a framework for safe medication prescribing, and the dispensing, administering and monitoring of medications.
This Residential Aged Care Communiqué case study looks at the increased clinical risks and the need for heightened levels of supervision when a patient is moved to a different location or when there is a change in the staff providing care to the patient. We also examine the practice of using bedrails for preventing falls.